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LETTER TO THE EDITOR
Year : 2013  |  Volume : 2  |  Issue : 2  |  Page : 114-116

The underestimated nutritional aspects of micronutrients supplementation in intensive care


Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India

Date of Web Publication6-Jul-2013

Correspondence Address:
Sukhminder Jit Singh Bajwa
Department of Anesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-019X.114730

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How to cite this article:
Bajwa SJ. The underestimated nutritional aspects of micronutrients supplementation in intensive care. J Med Nutr Nutraceut 2013;2:114-6

How to cite this URL:
Bajwa SJ. The underestimated nutritional aspects of micronutrients supplementation in intensive care. J Med Nutr Nutraceut [serial online] 2013 [cited 2020 Dec 1];2:114-6. Available from: https://www.jmnn.org/text.asp?2013/2/2/114/114730

Sir,

Nutritional aspects have always been important determinants of clinical outcome in intensive care unit (ICU) patients. The severity of critical illnesses, numerous co-morbidities, varied clinical presentation, pre-admission nutritional statuses, and so many clinical factors make the assessment of nutritional requirements extremely difficult and challenging. So much stress has been laid on enteral and parenteral nutrition controversies that some other important nutritional aspects have been underestimated. Such nutritional practices definitely will impact the clinical outcome and has been the instrumental in increasing the morbidity and mortality in this subset of population.

Micronutrients have been generally overlooked during nutritional assessment, which has resulted in provision of sub-optimal nutrition in critically ill patients. Micronutrients such as zinc, selenium, copper, vitamin C, E, and B and others are important part of numerous metabolic reactions either acting as catalysts or helping various enzymatic functions. Micronutrient deficiency can result from pre-existing malnutrition, severity of current illness, and side effects of various therapeutic regimens or procedures. Such deficiencies can lead to depressed immunity, impaired wound healing, organ dysfunction, and increased morbidity and mortality. [1] The antioxidant role of micronutrients is highlighted by an increased oxidative stress with increase in concentration of oxygen reactive species and intermediates from their resulting deficiencies. [2]

Critical illness and the associated co-morbidities are invariably associated with increased production of oxygen reactive species and a relative deficiency of antioxidants and micronutrients. It has been generally observed in developing nations that dietary aspects are not considered in totality especially concerning the composition of micronutrients in the diet. During prolonged stay in ICU, such deficiencies in the diet may lead to impaired defence mechanisms and decreased production of anti-oxidants in vivo.

Recently, supplementation of diet with immunonutrients such as arginine, glutamine, γ-linolenic acid, polyphenols, and others has gained popularity in intensive care circle. [3] Though numerous recommendations are available from literary evidence, the biggest challenge for intensivists throughout the globe is the non-availability of universal guidelines and protocols related to micronutrient supplementation as a result of which no universal consensus exists among the intensive care fraternity. [4] Limited availability of literature related to exact requirement of micronutrients in critically ill patients is another big reason for lack of awareness among the intensivists. Further, the administration of these micronutrients has to be balanced as more than required quantity can produce toxic levels and can enhance morbidity and mortality. [5] Stress on single micronutrient does not yield any productive outcome but supplementation of combined micronutrients definitely helps in bringing down the morbidity and mortality in ICU. [6]

As with enteral and parenteral nutrition, controversies are also similar with regards to the route of micronutrient supplementation. [6] However, intravenous route is most reliable in terms of delivery of exact dose of micronutrients in critically ill patients as bowel edema, decreased peripheral perfusion in hypotension, hemodynamic fluctuation, and other causes in such patient population make enteral route an unpredictable one. [1] The optimal clinical results with micronutrient supplementation depend upon adhering to strict timing, and duration and doses of micronutrients. [7] Selenium is considered to be an important micronutrient in critically ill patients as the morbidity and mortality is increased in patients with decreased plasma levels of selenium. [8]

It has now been established that supplementation of micronutrients decrease the mortality ratio in critically ill patients. A need is felt to make the intensive care fraternity strongly aware about the possible role of micronutrients in improving the patient outcome in critically ill patients. With the availability of more and more literary evidence in the future, the role of micronutrients in improving the outcome in critically ill patients will be more defined once the universal consensus is formulated.

 
  References Top

1.Sriram K, Cue JI. Micronutrient and antioxidant therapy in critically ill patients. In: Cresci G, editor. Nutrition Support for the Critically Ill Patient. New York: Taylor and Francis/CRC Press; 2005. p. 109-23.  Back to cited text no. 1
    
2.Lovat R, Preiser JC. Antioxidant therapy in intensive care. Curr Opin Crit Care 2003;9:266-70.  Back to cited text no. 2
    
3.Mizock BA. Immunonutrition and critical illness: An update. Nutrition 2010;26:701-7.  Back to cited text no. 3
    
4.Fuhrman PM, Herrmann VM. Micronutrients in critical illness. In: Shikora SA, Martindale RG, Schwaitzberg SD, editors. Nutritional Considerations in the Intensive Care Unit. Silver Springs: American Society for Parenteral and Enteral Nutrition; 2002. p. 51-60.  Back to cited text no. 4
    
5.Berger MM, Shenkin A. Update on clinical micronutrient supplementation studies in the critically ill. Curr Opin Clin Nutr Metab Care 2006;9:711-6.  Back to cited text no. 5
    
6.Heyland DK, Dhaliwal R, Suchner U, Berger MM. Antioxidant nutrients: A systematic review of trace elements and vitamins in the critically ill patient. Intensive Care Med 2005;31:327-37.  Back to cited text no. 6
    
7.Mishra V. Oxidative stress and role of antioxidant supplementation in critical illness. Clin Lab 2007;53:199-209.  Back to cited text no. 7
    
8.Angstwurm MW, Gaertner R. Practicalities of selenium supplementation in critically ill patients. Curr Opin Clin Nutr Metab Care 2006;9:233-8.  Back to cited text no. 8
    




 

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